Musings in the life of an internist, cardiologist and cardiac electrophysiologist.

Saturday, October 25, 2008

Ten Times the Fun

According to the bureaucrats, if you want to impose "cost saving measures" to correct our complicated health care system, do everything in your power to make it more complicated.

In fact, make it at least TEN TIMES more complicated.

Take for instance, our current coding scheme for classifying diseases called ICD-9 codes. (ICD-9 stands for the ninth revision of the "International Statistical Classification of Diseases and Related Health Problems"). These codes are required on every insurance claim to justify a payout on behalf of the patient. If a procedure code does not match the appropriate disease code on an insurance claim.... BOOOIIINNNNGGGG, the insurance claim is denied, and Medicare and the insurers save money.

These codes are a picture of clarity. I mean, let's hear it for 427.0! Oh, baby, I can get my head around that code, can't you?

What, you don't know what that means?

Why, "SUPRAVENTRICULAR TACHYCARDIA!" I mean, I knew that, why didn't YOU? Sheesh! Any REAL doctor knows THAT code. After all, it makes so much sense, right? And 427.1? Why heck, any well-respected doctor should immediately be able to intuit that the code is used to denote VENTRICULAR TACHYCARDIA! What, you're lost? How can that be? I mean, it's so CLEAR!

And on and on it goes, some 17,000 codes for 17,000 kinds of ailments.

But for bureaucrats, 17,000 codes are not enough. They want MORE! Many, many more. And so, ladies and gentlemen, they have announce the introduction of...

Yep! Welcome to the world of the soon-to-be-enacted NEW AND IMPROVED 10th revision of the ICD codes with a staggering 155,000 codes to be implemented on 1 October, 2011!

Imagine, 290 codes just for diabetes! Yeeeee haaaaa! Diabetes with foot ulcers on the right foot gets one code, diabetes with foot ulcers on the left foot gets another code, diabetes with foot ulcers on both feet, but not involving the shins gets another code... I mean, a new code for every nuance of disease! You get the drift! Isn't this SPECIAL? Just think of the COST SAVINGS those clever bureaucrats have found!

Oh, wait.

Someone actually looked at the cost to implement this "cost-saving" coding scheme for doctors, and here's what they found:

The total estimated cost for a 10-physician practice to move to ICD-10 would be more than $285,000. These expenses include:

Training expenditures are estimated to total $4,745

New claim form (superbill) software $9,990

Business process analysis $12,000

Practice management and billing system software upgrades $15,000

Increases in claim inquiries and reduction in cash flow of $65,000

Increased documentation costs $178,500

For a small, three-physician practice, the total cost to implement ICD-10 is estimated to be $83,290, for a large, 100-physician practice the estimated costs to implement ICD-10 is more than $2.7 million.

Heck, I'm on board, aren't you? Especially since most stand-alone physician practices can't even afford yesterday's electronic medical record that will be obsolete before it's installed. Look, for instance, at this comparison of a family practice doctor's current 2-page "superbill" that will expand to a 9-page "superbill" using the newly proposed coding scheme.

Crazy.

But lets not fool ourselves. This is exactly what the government wants: more complexity and bureaucracy in the name of lower "costs." One only needs to see how the government calculated their "cost" savings for justifying the massive increase in complexity to the coding scheme:

Benefit Assumption 1: Based on the data provided in a recent AHIP report the percentage of pended claims was assumed to be 14% of total claims.

Benefit Assumption 2: Pended claims will be reduced by 0.28% (minimum) to 0.7% (maximum). Using the research and interviews, it was assumed that the pended claim percentage, currently 14% (Benefit Assumption 1), would be reduced through standardization.

Benefit Assumption 3: Reduced manual intervention will reduce the costs for providers by $3.20 per call and for plans by $1.60 per call. Manual intervention is required to resolve pended claims and both Healthcare providers and Health Plans incur these operational costs.

Yep, there you have it. CMS has justified the most massive expansion of electronic coding so "providers" and massive health systems can get their money without having to pick up the phone.

But just in case doctors aren't too keen about the complexity and expense of electronic medical records for their office due to the carefully-planned obsolescence of new systems, doctors are also being forced to e-prescribe next year in order to gain 2% more of their Medicare payment they were due.

My friends, soon we will see that the Beast has won. Independent stand-alone physician practices will soon be a thing of the past, brought to their knees by overbearing electronic billing and prescribing regulatory requirements. In their place will be physician-employees of major health care systems that are capable of purchasing computers, personnel and electronic reimbursement software upgrades annually, while they are subject to data-mining algorithms to assure "efficiencies" and "effectiveness" and "quality," all in the name of cost-savings.

Too bad its the patients who will ultimately have to bear the costs for this.

7 comments:

Technically, it isn't really 17,000 different ailments, but rather 17,000 reasons for a healthcare encounter. For example V20.2 (don't you know that one by heart too? C'mon; and you call yourself a *doc*! /sarcasm) for a well child visit, E812.0 for being the driver in a motor vehicle accident, etc. ad nauseum.

Unbelievably, the official release format ICD-10-CM is a 2,392 page, 23MB PDF. How can a major coding system that's supposed to revolutionize health care data come as a text blob? You can't even load the thing into a spreadsheet or database table!

For more problems with ICD-10-CM, see the Better Diagnosis Coding blog.

I slightly disagree. Yes, ICD-10 in the current world would be overwhelming to implement, but in a more electronic world, where the codes could be AUTOMATICALLY calculated based on a structured-and-codified but well-designed (i.e. fast to use, easy to learn, and possible to read) EMR, ICD-10 wouldn't be the problem it is in the manual world. So perhaps ICD-10 per se is no so much the problem as the TIMING of implementation. I would predict such EMRs in wide use in 9-10 years from now, but I'm an optimist.

I did puck up on your e-Prescribing comments. You belive this will be harmful to practice, and I strongly disagree with that. In fact, I CHALLENGE you to try a well-written eRx application for 1 month and then make the same statement. (DISCLAIMER: I work for a company that produces a well-written eRx application) Also, that 2% incentive is now reported to be based on ALL Medicare Part B, not just E&M, so that should help an invasive cardiologist a bit more than expected.

Increasingly, administrative tasks and requirements mandated by governmental bodies are relegated to physicians. In order to complete these required tasks, doctors are increasingly required to finance the infrastructure for their implementation at a time our payments from these same regulatory bodies have not kept up with inflation. While I agree that e-prescribing is important from a safety and efficiency perspective (we already have a fully implemented system here), for the private physician group without that infrastructure, no one seems too concerned that doctors will have to eat the costs to implement it. Will 2% of $70 dollar/visit patient appointments pay for the infrustructure? No way. As these new systems requirments continue to directly impact doctors' practices, the incentive to maintain the practices' status quo will dissolve and will likely negatively impact the physician workforce.

This is misleading. ICD-10 is a coding system where each character stands for a different aspect of disease. It is much more logical than ICD-9, and as Dr. Kaufman says, when you have well structured electronid documentation, A computer could produce the ICD-10 codes.

It's poetic justice, that's all: doctors who've resisted publishing their rates for all these years are now going to become government employees, typing and coding their lives away.

Too bad for the public, but the doc gods deserve such treatment in payment for all those years of disrespecting their clients and the public. Just try calling MD Anderson and ask what they charge for a colonoscopy. You will end up at the supervisor level and get your answer after 1 hour of holding and transfering. I know: I just did it.

Ridiculously late ttoiisposting, t of course the reason the prices are not posted is that doctors are not allowed to discuss prices with each other and two, the patient is not the customer. The insurance company is.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.